Summary While on a search and rescue mission on the south arm of the Fraser River, the Canadian Coast Guard hovercraft Siyay struck a rock breakwater on the west side of a gap in the jetty. There were no serious injuries as a result of this occurrence, but the craft sustained significant damage. Ce rapport est galement disponible en franais. Other Factual Information Description of the Craft The Siyaywas built in 1998 by GKN Westland Aerospace (sub-contracted to Hike Metal Products Limited, Wheatley, Ontario) for the Canadian Coast Guard (CCG). The AP1-88/400 is a hovercraft, which travels on a fan-generated cushion of air, with propulsion provided by two variable-pitch propellers. The hovercraft is equipped with a removable crane (not on board at the time of the occurrence) and has a payload of up to 25000 kg, allowing for great flexibility for transporting a combination of freight and passengers. Vehicles can be loaded directly on deck through a bow ramp. These features, as well as being fully amphibious, make the AP1-88/400 particularly useful in oil pollution clean-up operations and other applications, including search and rescue (SAR) and aids to navigation maintenance and construction. The control cabin of the Siyay,similar in design to that of an aircraft, is near the after end of the craft (seePhoto1). The design allows for an excellent view forward, with the exception of the bow thruster vents to port and starboard at the forward end of the craft, which cause blind sectors. Operationally these blind sectors are overcome by the craft captain and port seat occupant exchanging information as targets move from one sector to the other. The control cabin consists of four seats, two forward and two aft. Manoeuvring- and navigation-related instrumentation is arrayed across the fore part of the control cabin, below the windows (seeFigure1). Dual control levers for the propulsion system are in a centre console between the two forward seats. Dual controls for the bow thrusters are immediately in front of each forward seat. The very high frequency radios are on the centre console, and communication is via headsets. Navigation instrumentation consists of a radar, gyro, global positioning system, and depth finder. An additional radar is in the after part of the control cabin in a position accessible to the port side seat occupant. Figure 1. Instrumentation in the fore part of the AI1-88/400 control cabin. The craft captain normally occupies the starboard forward seat, the navigator the port side forward seat during daylight operations; the two additional crew members occupy the after seats. During night-time operations, the navigator occupies the port after seat. The distance from the fore part of the control cabin to the bow is 13.1 m and to the stern 15.4 m. The CCG Sea Island Base in Richmond, British Columbia, had been operating two SRN-6 hovercrafts in continuous SAR service since August 1968 (seePhoto2). In 1993, the CCG identified the need for a hovercraft replacement program for the two SRN-6s at Sea Island Base and recommended the AP1-88, in part because of its multi-mission capabilities. In 1987, the CCG Laurentian region received an AP1-88/200 series hovercraft (WabanAki), which has since been in continuous service performing duties in SAR, ice-breaking, oil spills, and servicing and recovering large navigational buoys along the St. Lawrence. The expanded operational capabilities of the AP1-88 units, particularly the servicing and recovering of large navigational buoys is a task normally associated with conventional workboats and CCG ships. The CCG was very satisfied with the performance of the Waban Aki, and the decision to order the larger AP1-88/400 series hovercraft was based largely on the opportunity to enhance operational capability, particularly the ability to carry more and larger buoys. In April 1998, the Laurentian region received the AP1-88/400 Sipu Muin, followed by delivery of the sistership Siyayto the Western Region in November 1998. Photo 2. The Canadian Coast Guard's SRN-6 hovercraft. History of the Voyage The Siyay departed Sea Island Base on the evening of 14 July 1999, for patrol and training exercises. The crew configuration consisted of the craft captain seated at the controls on the starboard side and the lookout occupying the forward port seat position in the control cabin. The first officer (navigator) and a SAR specialist were seated on the port and starboard after seats, respectively. At 2330 Pacific daylight time, the crew received a call from the Victoria Rescue Co-ordination Centre (RCC), just as they had completed night-time beach landing exercises on Shingles Point, Valdes Island, which is on the west side of the Strait of Georgia, some 16miles from the entrance of the Fraser River at Sand Heads (seeAppendixA). The crew was instructed by the RCC to search for a pleasure craft reported to be aground 0.25miles southwest (downstream) of Steveston, on the south arm of the Fraser River. The Siyay entered the Fraser River via Sand Heads at 2400, on the south side of the Steveston Jetty. Heading towards Steveston, they searched the area along the jetty using their searchlight. They were later informed by RCC that the craft was on the north side of the jetty, whereupon the craft captain turned the craft around, heading westward along the jetty wall. The jetty wall contained a number of gaps, and the craft captain decided to attempt passing through one of these gaps located between beacons nos7 and7A, to reach the north side as quickly as possible. An alternative was to navigate around Sand Heads, which would have taken several extra minutes. The crew located a gap in the jetty using radar, lined up the craft with the aid of light buoy NoS6, and then proceeded toward the gap on a visual approach. The pilot was operating the starboard searchlight, maintaining focus on the east end of the gap, while the lookout used the port searchlight to maintain reference to the west side of the gap. As the craft captain approached the gap, he lost visual reference to the east side, and consequently became concerned about where the craft was in relation to the gap. The craft captain attempted to rotate his searchlight to illuminate the west side of the gap, but in doing so, the searchlight lit up the bow thruster vents, making visual reference even more difficult. At this point,, the craft captain reduced speed and attempted to steer using the compass. The reduced speed resulted in greater spray, which created a large amount of visual clutter because it was illuminated by the searchlight. The poor visibility made attempts at reestablishing visual contact with the gap even more difficult. The crew reported feeling the craft move sideways as the bow passed through the gap, immediately followed by the port side of the craft contacting the west side of the jetty. Time of contact was estimated to be 0019, on 15 July 1999. The craft returned to base unassisted. Injuries to Persons Damage Approximately 6.5m2 of hull plating and internal framing (between frames 7.1and12) sustained damage on the port side of the craft. Damage to the starboard side consisted of a crack at the T-section of extrusion at frame11. The aft landing pad debris guard on both sides of the craft was damaged. Extensive damage was sustained by the cushion skirt on the port side of the craft. There was no pollution as a result of the occurrence. Personnel Certification and Experience There were four crew members on board the Siyay. The craft captain held a CCG Watch Keeping Mates (WKM) Certificate of competency. He joined the CCG hovercraft unit in 1980, serving as first officer until 1983 after which he served as pilot.1 He has operated SRN-5 and SRN-6 hovercrafts during this period; training on the AP1-88/400 beginning in 1999. The pilot had successfully performed a practical examination in the operation of the craft in the presence of Transport Canada, Marine Safety (TCMS). He had not taken bridge resource management training, which is not mandatory. The first officer/navigator held a WKM certificate and had one year of experience on hovercrafts. One SAR specialist had six months' experience on hovercrafts, and the other SAR specialist/lookout had one month's experience. Craft Certification The craft was inspected in accordance with Transport Canada (TC) requirements. It operated with an Air Cushion Vehicle Safety Certificate - Special, issued by TCMS, in Vancouver on 15 February 1999. Environmental Considerations Visibility was good, with winds from the east at 12 knots. The river current was estimated at 3 to 5 knots in a west-southwesterly direction. The tide was ebbing, with a high water at Steveston predicted to be 4.0 m (13.1 ft.) at 2045, July 14, to a low of 3.1 m (8.5 ft.) at 0120, July 15. The craft struck the jetty approximately one hour before low water. The 16th edition of Sailing Directions, British Columbia, South Coast, has a cautionary note, which reads as follows: Steveston Jetty has several gaps in it through which a cross current flows and on ebb tides extremely turbulent water exists in the vicinity of the rock groyne at Steveston Bend. The gap through which the Siyayattempted to navigate was some three cables west of Steveston Bend. Duty Times The Sea Island Hovercraft Unit operated 24 hours a day, 365 days a year. Crews worked on a four-days-on, four-days-off cycle. Days one and two are from 0800 until 1800, and days three and four from 1800 until 0800. AP1-88 Service Entry Plan The Sea Island Hovercraft Unit developed a service entry plan for the AP1-88. The last update to the plan prior to the occurrence was in April 1999, to bring the craft into service by 17 May 1999. The plan consisted of five phases, including acceptance of the craft, structural changes required to the craft, regulatory endorsement of type rating, and a wide variety of training requirements to ensure that the AP1-88 service requirement would be met. The demands on personnel operating high speed craft are well documented by the CCG and the Sea Island Hovercraft Unit. Therefore, a service entry plan for the new generation AP1-88 was developed to phase in the transition period. The last update to the plan prior to the occurrence was in April 1999, to bring the craft into service by 17 May 1999. The five part plan considered all aspects of operating a large displacement (all up weight) hovercraft under the High Speed Craft Code, including factors such as craft familiarization, crew fatigue, environmental hazards, craft limitations, and crew complement. The monitoring program included a feedback mechanism to inform CCG management if the goals and corresponding time lines proved ambitious, or resources became exhausted. Recommendations from the service entry plan included a communications exchange database for operations personnel receiving training; instrument controls familiarization; customizing manufacturer's operating and machinery manuals; crew recruitment; development of a detailed trials program (program specific); and performance measurement matrix development. The service plan also identified the need to develop a future task analysis program for enhanced roles within CCG for the AP1-88. However, this activity would not be entertained until the level of service with the AP1-88 (craft and crew performance) met the existing SRN-6 standard. Ergonomics of the AP1-88/400 During the design stage of the Sipu Muin and Siyay, personnel of the CCG Ship Safety Branch (now TCMS) and SAR hovercraft pilots monitored the work, while GKN Westland Aerospace staff acted as project advisors. There were no CCG ergonomic or human factor advisors or programs in place during the acquisition, design, and testing stages. During the investigation, a number of ergonomic design problems were identified, particularly for SAR night-time operation, including: obstructed field of view from the control cabin, caused by the bow thruster vents; side windows were not inclined and therefore reflections were problematic at night; searchlights were designed for two-handed operation by someone other than the pilot (one hand is required to stabilize the unsecured control unit, while the other hand is needed to operate the joystick); some navigation equipment did not allow for individual control of illumination and lighting; night-time operation required relocation of navigator from fore to aft of the bridge, because the light from the radar reflected on the control cabin windows affecting the ability to see out of the windows and the crew's night vision; light from search beams reflected off the water spray from the bow of the craft,2 thereby obscuring forward visibility from the bridge at night. Hovercraft Pilot Training The pilot is in charge of the craft controls. Prior to acquiring the AP1-88/400, Sea Island Base chartered an AP1-88/300 craft to allow a day of classroom training followed by five hours of practical training, for each captain. Formal training of pilots to operate the AP1-88/400 consisted of a two-week classroom systems course, provided by the manufacturer (Westland) in April 1998. The rest of the training was provided in-house. The west coast hovercraft pilots spent one to two weeks on the Sipu Muin in the Laurentian region. Night operational training on this type of hovercraft was not included in the Laurentian training program, as they do not have personnel highly experienced in night-time hovercraft operations. For training in general hovercraft night operations, the Laurentian region had gone to the west coast region for training (performed on the SRN-6). The in-house training program for the craft captains learning to operate the AP1-88/400 was relatively unstructured. A training profile had been constructed for each of the craft captains, but adherence to and monitoring of the profile was not consistent. After returning from the one to two weeks of training in the Laurentian region, a Pilot Standards Officer (a pilot from the Laurentian region with experience on the AP1-88/400) was on base to guide training exercises and to provide a check out to pilots wishing to attain solo status; however, this was not a dedicated training position. In essence, the west coast craft captains continued to learn how to operate the Siyay on a self-taught, on-the-job-training basis. No formal assessment of pilot proficiency was conducted on the Siyay for SAR operations. No periods of time were specifically dedicated to training. Training time was taken on a time permitting basis between operational activities. Concomitant with the west coast pilots learning to operate the AP1-88/400, they were trying to develop a training program for future pilots. Hovercraft Crew Training There was no formal training for work on hovercrafts for the rest of the complement of the four-member crew. Training took place on the job and was at the discretion of the craft captain piloting the craft. The Effect of Staffing Levels on Training The unit at Sea Island experienced a severe decrease in the number of experienced hovercraft pilots in the three years prior to acquiring the Siyay. According to CCG policy, Sea Island should have had 11 pilots and an officer in charge. At the time of the accident, Sea Island was four officers short. Typically, three years are required to train an officer for the command position of the SRN-6 hovercraft and approximately six to eight months on the SRN-6 for a mate to become first officer. Minimum new entry requirements for pilots is WKM Certificate of Competency. A limited number of hovercraft pilots are qualified by the CCG each year. Seven pilots were qualified in 1998, but these pilots were placed on ships rather than the hovercraft unit at Sea Island. Temporary staffing of hovercraft pilots is rarely possible because of the unique skills required in operating a hovercraft. Policy Regarding SAR Mission in the AP1-88/400 CCG policy states that if a vessel is operational, it can be tasked by RCC for a SAR mission, although the pilot retains the final decision on whether or not to respond. No formal operational standard was used to determine when a particular crew was deemed operational. The informal base policy was that craft captains use their own discretion to decide whether to use the AP1-88/400 or the SRN-6 on a SAR mission. Procedures An AP1-88/400 procedures manual had not been developed. The AP1-88/400 Hovercraft Type Operating Manual was prepared and issued by GKN Westland Aerospace for training purposes only. During both training and operations at Sea Island Base, many aspects of operation were left to the discretion of craft captains on duty. Crew members reported observing wide variation among craft captains in the operation of the SRN-6 and the AP1-88/400, and in their teaching of procedures. Fitness to Work CCG policy requires that all individuals on medical stress leave comply with a manager's request for a fitness to work assessment prior to returning to duties. During the course of the investigation, it was established that one of the crew members had been on stress leave seven months prior to the occurrence, but that the assessment process had not been applied uniformly. In a TSB investigation of a collision involving a CCG vessel (Report NoM91C2004), the Board identified the lack of a formal mechanism within the CCG to identify and monitor persons who are not medically fit for duty and who occupy safety-sensitive positions, such as ships' officers and pilots. As a result of that investigation, the Board recommended that: The Department of Transport, in cooperation with Health Canada and the Canadian Coast Guard, define policies and procedures to ensure that personnel returning to safety-sensitive duties following any medical treatment are fit for those duties. As a result, the CCG uses the services of Health Canada's Occupational Health and Safety Agency (OHSA) to assist in setting the criteria for evaluating the health of CCG employees, including fitness to work criteria. The assessments are performed by physicians and occupational health nurses. The purpose of any type of OHSA health assessment is to provide a manager with a means for determining whether an employee is healthy enough to perform optimally and safely, given the demands and risks of the job.